EHJ September 2003 page 261-263 The publication of the Northern Ireland Government's Investing for health strategy marked a shift in health policy, placing the emphasis on prevention rather than cure. Nick Warburton looks at the vital role environmental health has in contributing to its realisation

Despite general improvements over the last century, too many people in Northern Ireland still suffer from high levels of ill health, particularly when compared with many other western European countries. In a country populated by around 1.685 million people (national statistics census 2001), it is estimated that preventable ill health causes around 6,500 deaths each year - all of which are avoidable. Coronary heart disease, cancer and respiratory disease are the main causes of illness and morbidity for both sexes, accounting for 65 per cent of all deaths.1

Like many parts of the UK, the province also continues to experience significant health inequalities, with a notable widening in the gap between the rich and poor in the past few decades. Urgent action is required to bring Northern Ireland's health standards up to the level of those in the best regions of Europe.

The launch of the Investing for health strategy in March 2002 signalled an important sea change in health policy and a significant commitment from the government in Northern Ireland to work to improve the population's health and reduce health inequalities. Until its publication last year, health policy had tended to focus on the treatment of ill health. However, with the launch of the strategy came an acknowledgement that tackling the wider determinants of health - the factors that cause poor health within the social, economic, physical and cultural environment - was vital.

Representing a new cross-cutting, inter-departmental strategic approach to public health, Investing for health has been enthusiastically welcomed by many in the environmental health profession. As Nigel McMahon, chief environmental health officer at the Department of Health, Social Services and Public Safety, explains, many environmental health practitioners (EHPs) acknowledge the opportunity that the strategy provides to refocus efforts on the public health agenda locally.

"Like elsewhere in the UK, the environmental health service in Northern Ireland has become increasingly fixed on statutory enforcement duties," says Mr McMahon. "Investing for health contains an evidence base and focus on public health outcomes that has reawakened the debate about the future role of EHPs in delivering the public health agenda."

Investing for health contains a framework for action to improve health and wellbeing and reduce health inequalities through partnership working. Comprising two overarching goals and seven objectives, each with specific targets, it aims to pull various government departments, public bodies, communities, voluntary groups, district councils and social partners together.

The object of the first goal is to improve the health of the population by increasing life span and the number of years people spend free from disease, illness and disability. It is hoped that by 2010, the various stakeholders can work together to improve the levels of life expectancy in Northern Ireland to meet the levels of the best EU countries; this means increasing life expectancy by at least three years for men and two years for women.

The second goal aims to reduce the inequality in health between geographical areas, socio-economic and minority groups. Two targets have been set, both of which, it is hoped, will be met by 2010. The first is to halve the gap in life expectancy between those living in the fifth most deprived electoral wards and the average life expectancy for both men and women. The second is to reduce the gap in the proportion of people with long standing illness between those in the lowest and the highest socio-economic groups by a fifth.

The seven objectives meanwhile each have different target dates, ranging from 2004 to 2010. Each of the different targets are fully explained in the strategy document, but the overall objectives are:

• to reduce poverty in families with children;
• to enable all people, and young people in particular, to develop the skills and attitudes that will give them the capacity to reach their full potential and make healthy choices;
• to promote mental health and emotional wellbeing at individual and community level;
• to offer everyone the opportunity to live and work in a healthy environment and to live in a decent affordable home;
• to improve neighbourhoods and the wider environment;
• to reduce accidental injuries and deaths in the home, workplace and from collisions on the road; and
• to enable people to make healthier choices.

According to Michael Bloomfield, principal officer in the strategy team at the Department of Health, Social Services and Public Safety, Investing for health differs from the public health strategies in many other countries in that its objectives and the associated targets are not focused on disease. Since its launch, the focus of the strategy has been on developing and building processes and structures to ensure that it is successfully implemented. Considerable progress has been made during the first year, particularly at the local level where "investing for health" partnerships have been established in each of the four health and social services board areas.

These partnerships comprise the key statutory, community and voluntary interest groups in the local area as well as the various social partners that have a role to play. As Mr Bloomfield explains, "slightly different arrangements have been adopted in each area to reflect the varying levels of existing structures and networks already in place." However, common to all of the areas, notes Mr Bloomfield, "has been the high level of enthusiasm and commitment demonstrated by partner organisations to work together to make real and lasting improvements to the quality of life of people in their area."

In recognising the need to tackle the wider determinants of health, the main purpose of these partnerships has been to identify opportunities for improving the health of people in each of the board areas. As a result, the four partnerships each produced a health improvement plan (HIP), which was submitted to the Northern Ireland Government's Ministerial Group on Public Health (MGPH) in March 2003 for consideration.

The HIPs set out how each partnership plans to tackle the health and wellbeing needs of their local communities in order to meet the strategic aims and objectives of Investing for health. The plans have since been approved by the MGPH and endorsed by the Minister for Health, Social Services and Public Safety. Environmental health departments within the district councils have been key participants in these partnerships as well as the development of the HIPs. EHPs throughout the province are also playing a leading role in delivering one of the key Investing for health targets relating to local air quality. This target aims to reduce the levels of respiratory and heart disease by meeting the health-based objectives of the seven main air pollutants by 2005.

"EHOs in district councils are driving the local air quality management process despite the fact that several key functions, such as roads and planning, lie within central government in Northern Ireland," says Mr McMahon. "The recently introduced legislation supports them in this role and recognises that councils are best placed to work with partners to strategically plan for ultimate health gain."

The profession's commitment to partnership working is indeed long standing. As Mr McMahon explains, its ability to effect real change has already been demonstrated through a wide range of initiatives, including healthy cities, health action zones, Local Agenda 21 and local strategic partnerships, and continues in areas such as sustainable development and healthy living centres. "Many environmental health commentators have said that the profession has reached somewhat of a crossroads in relation to its role in public health," says Mr McMahon. "I believe that the district council environmental health service is already one of the cornerstones of efforts to improve and protect public health. The ongoing statutory work and partnership working across a range of initiatives stands testament to that."

Besides the many examples of environmental health good practice throughout the province, the profession is forging ahead on a strategic level with moves to change the planning process and a proposal to secure joint appointments between local authorities and health boards (see page 264).

The Northern Ireland Government has also made two other commitments, which Mr McMahon says could have a more fundamental and far-reaching impact in terms of how the profession contributes to the emerging public health agenda. These are the review of public administration and the review of the public health function (see page 266).

CIEH president Brian Hanna is a member of the steering group that will oversee the review of the public health function, which is due to be completed in February 2004. He is positive about the review's outcome and says that it could present the profession with an opportunity to become fully and actively involved, together with the other relevant partners, in promoting and improving public health in the province.

The review process is timely, coinciding as it does with the publication of the joint Health Development Agency/CIEH vision statement for the development of environmental health, Environmental health 2012 - A key partner in delivering the public health agenda. The Northern Ireland Chief Environmental Health Officers Group has already endorsed this important document and further work is planned to disseminate its message within the profession locally and through the wider public health network.

Through the involvement of Mr Hanna on the steering group and through other key environmental health representatives who are likely to be consulted on both reviews, Mr McMahon says that the Environmental health 2012 report and its out workings will provide valuable input. At the same time, he says the reviews may also provide "a vehicle to put in place some of the building blocks that would allow the Environmental health 2012 vision to be realised locally."

Like the CIEH president, Mr McMahon recognises the great opportunity that now exists for the profession to play a key role in the influence and delivery of the public health agenda. "The reviews of the public administration and public health function, and the development of the Environmental health 2012 vision, taken together, provide arguably the best opportunity for a generation to place environmental health where it can best contribute to health development and wellbeing," he says.

"They say timing is everything and the timing appears to be right. The stars, or at least the strategic reviews and the visioning process, have aligned!," he adds. "The question now is whether the environmental health profession in Northern Ireland can argue its case and make best use of the opportunity."

References

1. Investing for health, Department of Health, Social Services and Public Safety, March 2002. www.dhsspsni.gov.uk/publications/2002/investforhealth.html